Provider Demographics
NPI:1689636359
Name:TAMMERA, GRACE DIANE (OD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:DIANE
Last Name:TAMMERA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1192 WHITE HORSE RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043
Mailing Address - Country:US
Mailing Address - Phone:856-428-0100
Mailing Address - Fax:856-616-9670
Practice Address - Street 1:1192 WHITE HORSE RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043
Practice Address - Country:US
Practice Address - Phone:856-428-0100
Practice Address - Fax:856-616-9670
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00448900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
110958OtherBLUE CROSS BLUE SHIELD
110958OtherOPTICHOICE
2140021000OtherAMERIHEALTH
23377OtherAVESIS
20041OtherSUS
2K1265OtherHEALTHNET
P900553OtherOXFORD HEALTH PLAN
11534OtherSPECTERA
116890OtherEYEMED
NJ34890OtherAETNA
0080353000OtherAMERIHEALTH
42934OtherDAVIS VISION
42934OtherDAVIS VISION
U17703Medicare UPIN